Request an Appointment

This online request form is to be used for non-urgent appointments. For medical emergencies, dial 911.

With this form, you are submitting a request for an appointment - you are not scheduling the appointment. We will make our best effort to schedule your appointment or contact you within two business days. If you require more immediate service please call our office at 704.861.1208

Required *

Appointment Basics

Your first name *

Your last name *

Email address *

Best daytime phone number to reach you at *

Is this appointment for you or someone else? *
Me
Someone Else

Patient Information

Patient first name *

Patient middle name

Patient last name *

Sex
Male
Female

Date of birth

Address line 1 *

Address line 2

City *

State *

Zip code *

Home phone number *

Appointment Details

Primary reason for the appointment *

Preference for day/time of appointment

Were you referred by a health care provider?
Yes
No

If yes, name of the health care provider who referred you

Referring provider specialty

Referring provider city and state

Are you an existing patient of Dr. Kelly's? *
Yes
No, requesting first visit